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Crural Bypass Surgery in Case of Critical Ischemia: Technical Aspects and Results
1Department of Vascular Surgery, Hospital Carl-von-Basedow, Merseburg, University teaching Hospital (University of Halle), Weiße Mauer 52, 06217 Merseburg, Germany.
Insights
Crural bypass surgery offers good long-term survival and low amputation rates for critical limb ischemia. Early intervention in peripheral arterial disease (PAD) stages III and IV improves outcomes, justifying the procedure.
Area of Science:
- Vascular Surgery
- Peripheral Arterial Disease Management
- Limb Salvage Procedures
Background:
- Crural bypass surgery is a critical intervention for limb salvage in advanced peripheral arterial disease (PAD).
- Outcomes of crural bypasses are often less favorable than more proximal arterial reconstructions.
- This study evaluates the justification and outcomes of crural bypass surgery based on various surgical factors.
Purpose of the Study:
- To determine the success of crural bypass surgery in terms of patency, survival, and amputation rates.
- To compare outcomes based on peripheral arterial disease (PAD) stage, bypass material, and recipient vessel.
- To assess the overall justification for performing crural bypass surgery.
Main Methods:
- Retrospective analysis of 102 crural bypasses performed between 07/2013 and 06/2018.
- Patients had critical PAD (Fontaine stage III or IV).
- Evaluated endpoints included major amputation or death, with analysis of patency rates, survival, and influencing factors.
Main Results:
- Amputation-free rates were 78% at 6 months and 70% at 24-60 months; survival rates were 83% (6 months), 78% (12 months), and 59% (40 months).
- Disease severity (stage III vs. IV) significantly impacted patency and amputation rates.
- Autologous bypasses did not show superior patency; minor amputations and anticoagulation regimens did not affect long-term results.
Conclusions:
- Crural bypass surgery demonstrates favorable long-term survival and low amputation rates, irrespective of the recipient outflow vessel.
- While autologous vein is preferred, graft prostheses yield comparable results.
- Early intervention for stage III PAD is crucial to prevent progression to stage IV and improve outcomes.
Abstract:
Background Crural bypass surgery is one of the last options to salvage the leg. Compared to arterial reconstructions of more proximal localization patency rates are generally less good. The aim of this retrospective study was to answer the question if crural bypass surgery is justified. For that we focused on different technicalities, bypass material, recipient vessel and anticoagulation regimes. Objective To know outcome of crural bypass in terms of patency rates, survival rates, amputation. The difference in outcome is compared in different stages of peripheral arterial disease and various bypass materials and sites. Method Between 07/2013 and 06/2018 we performed 102 crural bypasses (27 female, 75 male; age 44-90 (70) years). Reasons for the bypasses were a critical peripheral arterial diseases (PAD) (stage III [pain at rest] and IV [necrosis/gangrene] according to Fontaine). End point of the study was major amputation or death. All patients were operated on in the same department by two experienced vascular surgeons. Result Amputation-free time was 78% after sixmonths and 70% after 24 and 60 months. Six, 12 and 40 months survival was 83%, 78% and 59%, respectively. Patency rates were affected by the severity of the disease (stage III vs. stage IV) and so was major amputation. Autologous bypasses were not associated with a better patency rate. Minor amputation or the anticoagulation scheme did not influence the long term results. Conclusion The long term survival after crural bypass is good and amputation rates are low, independent of the vessel of the lower leg used as recipient outflow. Accordingly, if a bypass is technically feasible, there is no limitation regarding the choice of the recipient vessel. If possible, autologous vein should be used, but a graft prosthesis can lead to equally good results. As patients with stage III PAD have better outcomes, early intervention is recommended in order to avoid deterioration to stage IV.
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